Sunday, May 20, 2012

Abdominal examination - liver

1) Start the palpation in the right iliac fossa. If you
start in the right lumbar or right hypochondrium you may miss a massively
enlarged liver.

2) The radial border of the right hand is used to feel
the liver. The hand must be placed flat on the abdomen. Make sure you do not
poke the patient’s abdomen with your finger tips.

3) Now your right hand is kept stationary and the patient
is asked to take a deep breath. During inspiration the diaphragm becomes flat
and pushes the liver downwards. Try feeling the edge when the patient inspires.

4) As the patient breathes out, move your hand up the
abdomen for 1-2cm. Step 3) is then repeated.

5) Repeat step 4) till you reach the costal margin or you
detect the edge of the liver.

6) If you feel the edge, then you have to work out
whether it is a true enlargement of the liver or the latter has been displaced
downwards by a hyperinflated lung e.g. in a case of emphysema. To check this,
you have to percuss the lung on the right hemithorax. The lower 3-4 intercostal
spaces are usually dull to percussion. If resonant then it is most probably a
hyperinflated lung.

7) If true enlargement is concluded then measure the
distance below the costal margin in the midclavicular line in cm.

Another way to perform the examination is:

1) Place both of
your hands side by side flat on the abdomen in the right iliac fossa lateral to
the rectus muscles with the fingers pointing towards the ribs. Feel the edge of
the liver with the pulp of your fingers, not your nails.

2) Repeat steps 3) to 7) as above but using the two hands
side by side method.

Other method, like using the left hand at the back and
palpating using the right hand in front, is also commonly used but it is less
accurate.

Now if you have an enlarged liver you have to describe it
in terms of:

a) Surface – smooth or irregular

b) Edge – smooth or irregular

c) Consistency – soft, firm or hard

d) Tenderness

e) Pulsatile

f) Audible bruit.

Causes of hepatomegaly:

1) Chronic parenchymal liver diseases like alcoholic
liver disease, autoimmune hepatitis, viral hepatitis, primary biliary
cirrhosis. Hepatic enlargement occurs mainly at the beginning of the diseases.
Later on, due to fibrosis, it shrinks. In these conditions the liver is usually
firm in consistency and regular surface.

2) Malignancy which can be primary hepatocellular cancer
or secondary metastatic cancer. In hepatocellular cancer, an audible bruit may
be heard while metastatic deposits give an irregular surface (sometimes
nodular) with hard consistency but without tenderness.

3) Right sided heart failure in which the lung will be
soft in consistency and can be tender.
If the failure is due to tricuspid regurgitation then we can feel a
pulsatile liver.

Interesting sites

Medicine is an ever-changing science. We tried putting up information as reliable as possible at the time of posting. We always recommend readers to confirm the posts from other sources also like from standard textbooks and universal agencies. The site is not an alternative to a proper medical evaluation and all information should be used using proper clinical judgement.

If you find any copyrighted material, let us know... we will remove it or ask for permission to publish.